Selling antibiotics without prescriptions among community pharmacies and drug outlets: a simulated client study from Ghana

Figures & data

Table 1. Simulated scenarios and the rationale for the selection and client assignment.

Simulated Case	Rationale for condition selection	Rationale for client assignment	Rationale for antibiotic demand and levels	References
Scenario 1 Upper Respiratory Tract Infections	URTIs were selected due to their common occurrence and prevalence in ambulatory settings where most cases can be managed without the use of antibiotics	Males were used in the URTI arm to balance for gender bias as this condition is not known to be gender-specific	Azithromycin was the specific antibiotic demanded on level one of the URTI case scenario as this is a prescription-only ‘Watch’ antibiotic and is indicated for the treatment of pneumonia and acute bronchitis in the NSTGs as well as for the treatment of COVID-19	[35,36]
Scenario 2 Paediatric Diarrhoea	This was chosen as the second simulation due to it also being a well-known self-limiting condition that is often viral and only requires rehydration even in exaggerated cases	Female clients were assigned to this scenario as they have been identified as usual caregivers to young children within the Ghanaian context	Amoxicillin-clavulanic acid, an ‘Access’ antibiotic, was demanded at the last level if no antibiotic was offered for previous demand levels.	[13]

Figure 1. Flowchart for the levels of demand in the two simulated cases used.

Table 2. Prevalence of antibiotics supplied without a prescription among drug outlets by type and case scenarios.

Metropolis	No antibiotic offered n (%)	Antibiotic offered n (%)	P value*
Pharmacy (N = 134)
Accra (n = 61)	6 (9.8)	55 (90.2)	0.03
Kumasi (n = 59)	3 (5.1)	56 (94.9)
Tamale (n = 8)	3 (37.5)	5 (62.5)
Cape Coast (n = 6)	0 (0.0)	6 (100.0)
Simulated Case
URTI (n = 70)	7 (10.0)	63 (90.0)
Paediatric Diarrhoea (n = 64)	5 (7.8)	59 (92.2)
OTCMS (N = 131))
Accra (n = 21)	6 (28.6)	15 (71.4)	0.15
Kumasi (n = 74)	7 (9.5)	67 (90.5)
Tamale (n = 26)	3 (11.5)	23 (88.5)
Cape Coast (n = 10)	2 (20.0)	8 (80.0)
Simulated Case
URTI (n = 67)	15 (22.4)	52 (77.6)	-
Paediatric Diarrhoea (n = 64)	3 (4.7)	61 (95.3)

*p-values compare the prevalence of offering antibiotic without a prescription across the four Metropoles, for both community pharmacies and OTC medicine sellers.

Table 4. Different types of antibiotics offered by pharmacies for both simulated conditions.

Antibiotics Offered	AWaRe classification	Pharmacy N = 129 n (n/N%)
		URTI	Paediatric diarrhea	Total
Metronidazole (with or without furazolidone)	Access	0(0)	56(43.4)	56(43.4)
Amoxicillin-clavulanic acid	Access	1(0.8)	5(3.9)	6(4.7)
Azithromycin	Watch	63(48.8)	0(0)	63(48.8)
Amoxicillin	Access	0(0)	0(0)	0(0)
Ciprofloxacin	Watch	0(0)	1(0.8)	1(0.8)
Trimethoprim-sulfamethoxazole	Access	0(0)	2(1.6)	2(1.6)
Flucloxacillin	Access	0(0)	0(0)	0(0)
Tinidazole	Unclassified	0(0)	1(0.8)	1(0.8)

AWaRe = Access, Watch, Reserve, URTI = Upper respiratory tract infection.

Out of these, a total of 41 different brands of antibiotics were identified during the study.

Table 5. Different types of antibiotics offered by OTC medicine sellers for both simulated conditions.

Antibiotics Offered	AWaRe classification	OTCMS N = 127 n (n/N%)
		URTI	Paediatric diarrhea	Total
Metronidazole (with or without furazolidone)	Access	2(1.6)	47(37)	49(38.6)
Amoxicillin-clavulanic acid	Access	14(11)	5(3.9)	19(15.0)
Azithromycin	Watch	30(23.6)	0(0)	30(23.6)
Amoxicillin	Access	7(5.5)	15(11.8)	22(17.3)
Ciprofloxacin	Watch	0(0)	1(0.8)	1(0.8)
Trimethoprim-sulfamethoxazole	Access	0(0)	5(3.9)	5(3.9)
Flucloxacillin	Access	0(0)	1(0.8)	1(0.8)
Tinidazole	Unclassified	0(0)	0(0)	0(0)

AWaRe = Access, Watch, Reserve, URTI = Upper respiratory tract infection, OTCMS = Over-the-counter medicine sellers.

Table 3. Antibiotic supply at various demand levels for both case scenarios among OTCMS and pharmacies.

Outlet type	No antibiotic offered n (%)	Antibiotic offered n (%)			P value*
		Level 1	Level 2	Level 3
Scenario 1 – URTI (N = 137)
OTCMS (n = 67)	15(22.4%)	29(43.3%)	2(3.0%)	21(31.3%)	<0.001
Pharmacy (n = 70)	7(10.0%)	55(78.6%)	8(11.4%)	0(0%)
Scenario 2 – Paediatric Diarrhoea (N = 128)
OTCMS (n = 64)	3(4.7%)	49(76.6%)	8(12.5%)	4(6.2%)	0.40
Pharmacy (n = 64)	5(7.8%)	49(76.6%)	9(14.1%)	1(1.5%)

*p-values compare the prevalence of offering antibiotic without a prescription by the levels of demand between community pharmacies and OTC medicine sellers, for both scenarios.

Figure 2. Antibiotic supply among attending staff in community pharmacies.

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